Primary Care Physicians and Early Detection of Alzheimer's Disease Part III

Published Online: Wednesday, November 16, 2011

This is the third part of our interview with Charles A. Cefalu, MD, professor and chief of geriatrics at the LSU Health Sciences Center School of Medicine at New Orleans, on the role of primary care physicians in early detection of Alzheimer's disease. To read the first part of our interview with Dr. Cefalu, click here. To read the second part, click here. To listen to the entire interview, click here.

MD P&P: How does one distinguish between dementia that’s due to Alzheimer’s and dementia that may be due to other syndromes or causes?
Cefalu: The main thing is the rapidity of the decline. Alzheimer’s is going to progress very slowly, very subtly over many, many months or years. It may be first picked up by the caregiver and denied by the patient, whereas the patient with other forms of dementia is going to present more with more atypical, abnormal, and possibly localizing neurological deficits that don’t fit the pattern. In other words, unusual neurological presentation: tremors, seizure activity, neurological deficits that are not symmetric that would key you into something going on. Falls, incontinence, things like that, a rapid decline over a period of weeks or months are certainly not consistent with Alzheimer’s disease.

MD P&P: Earlier this year, the first new diagnostic guidelines for Alzheimer’s disease in 27 years were released by the National Institute on Aging and the Alzheimer’s Association. In what ways should these new guidelines change PCPs’ approach to diagnosing Alzheimer’s?
Cefalu: Hopefully detection will be improved with the focus in these new guidelines on early detection rather than waiting to diagnose it later. We know that the longer you wait, the less of a chance you have to intervene and do something from a preventive standpoint. These guidelines are really out there to alert the primary care physician there is something you can do with early screening, with the appropriate testing and referral as necessary and certain medications—anti-depressants, anti-anxiety medications, and cholinesterase inhibitors.

MD P&P: Can information on whether patients have a genetic tendency toward Alzheimer’s help PCPs in detecting it early?
Cefalu: I think that’s helpful to know. Of course, I think the key for genetics is if there is early-onset Alzheimer’s in certain families, which is in the minority of Alzheimer’s cases to say the least, then that may be helpful. But genetic testing is kind of equivocal. People can have the APOE-4 gene for Alzheimer’s, but that doesn’t necessarily mean they are going to get Alzheimer’s. On the other hand, they may not have the gene and they may still get Alzheimer’s. You need to be careful with this genetic predisposition because to simply say that based on a test of genetic history you’re going to get Alzheimer’s can be very damaging. I would never want to label a patient with Alzheimer’s unless I’m absolutely certain because that can be like a death sentence to them. So, genetic history is important but it’s not that important. You need to take it into context with all the other signs and symptoms and the profile of the patient.

MD P&P: Under what circumstances should a PCP with a patient showing signs of Alzheimer’s refer the patient to a specialist or bring a specialist in to help with care?
Cefalu: If they’re looking at diagnostic testing, then referral to a radiologist for definitive testing in the form of a SPECT scan might be helpful. I would say that if as a primary care physician you feel that you do this on a regular basis and you’re comfortable with it, then you should proceed to do the screening and evaluate and manage that patient. I think it’s totally within the realm of the primary care physician, assuming you’re comfortable at least that the pattern is consistent with Alzheimer’s. At any point, if you feel like you’re not dealing with Alzheimer’s and your patient has an unusual presentation neurologically, both historically and physically, then I think you’re best off referring that patient to a neurologist or a psychiatrist or both for definitive diagnosis so there’s not misdiagnosis.

MD P&P: If Alzheimer’s is detected very early on when it would be classified as mild cognitive impairment rather than dementia, is there reason for hope at that point for treatment with drugs or other therapies?
Cefalu: Yes, the studies show that if you pick it up at a much earlier stage, you have a greater window for intervening and slowing down the process than waiting until later stages of the disease when deterioration has already occurred. We know that these drugs are much more effective in preventing further decline than waiting until the decline has occurred and then intervening.

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